Wound Healing

Question 1

wound

Answer 1

injury that breaks skin or other bodily tissues

Question 2

surgical wound

Answer 2

cut or incision made during surgery
purposely made
minimal tissue damage

Question 3

traumatic wound

Answer 3

sudden or unplanned injury
many wounds seen in ER/GP
bites, burns, lacerations

Question 4

wound healing

Answer 4

biological process
replace devitalized tissue and missing cellular structures and tissue layers
restores tissue after injury

Question 5

open (penetrating) wound

Answer 5

broken skin and exposed tissue
abrasion
laceration
puncture
avulsion
thermal wounds
surgical wounds or incisions

Question 6

abrasion

Answer 6

open wound
skin rubs or scrapes against a rough/hard surface
loss of epidermis and portion of dermis
usually no significant bleeding
scrub and clean wound to avoid infection

Question 7

laceration

Answer 7

open wound
cut or tear in skin, varies in severity and depth
if deep bleeding can be rapid and extensive

Question 8

puncture

Answer 8

open wound
small hole/wound by long sharp object
minimal skin damage but underlying damage may be severe
may not bleed much, but can damage internal organs
higher risk of subsequent infection by contamination at time of puncture – dirty wound

Question 9

avulsion

Answer 9

open wound
partial or complete tearing away of skin and tissue
traumatic injury, pieces of tissue torn and detached
bleed heavily and rapidly
crushing accidents, explosions, gunshots, head on collisions

Question 10

closed (non penetrating) wounds

Answer 10

damage to tissue under intact skin
usually secondary to blunt trauma
injured tissue not exposed, but can be bleeding and damage to underlying muscle, internal organs, bones
contusion
hematoma
crushing injury

Question 11

contusion

Answer 11

closed wound
blunt force trauma
does not break skin but causes damage to skin and underlying tissue
blood leaks from vessels
type of hematoma

Question 12

hematoma

Answer 12

closed wound
collection (pooling) of blood outside a vessel

Question 13

crushing injury

Answer 13

closed wound
force applied to area over period of time
commonly seen in bite wounds

Question 14

degloving wound

Answer 14

severe injury
top layers of skin/tissue ripped away in dramatic fashion

Question 15

other wounds

Answer 15

sinus tract injuries
burns
non healing wounds
open fractures
stings

Question 16

wound healing

Answer 16

multiple processes continuously interacting
restore tissue after injury

Question 17

factors that affect how well/quickly wound heals

Answer 17

environment/temperature – moisture favors bacteria
patient’s overall health
drug treatments

Question 18

phase I of wound healing

Answer 18

inflammatory phase
immediately after injury (within 5-10 mins)
minimizing blood loss by hemostosis
vasoconstriction, platelet aggregation, clot formation, vasodilation, phagocytosis
platelets start wound healing process – cytokines

Question 19

phase II of wound healing

Answer 19

proliferative phase
begins at 3-5 days, can last for several weeks
granulation contraction
epithelialization of injured tissue

Question 20

phase III of wound healing

Answer 20

remodeling phase
begins at ~3 weeks, can last weeks to months
formation of new collagen
wound tissue strengthening
scar formation

Question 21

6 basic steps of wound care

Answer 21

1. prevention of further wound contamination (lavage)
2. debridement of dead/dying tissue
3. removal of foreign debris and contaminants
4. provision of adequate wound drainage
5. promotion of viable vascular bed
6. selection of appropriate method of closure

Question 22

patient assessment

Answer 22

-hemodynamic stability – make sure patient stable before attending to wound
-hydration
-pain sensation, neuro function – important in limb injuries
-body condition
-organ dysfunction
-anemia – evidence of sepsis
-provide analgesia

Question 23

wound classification – clean

Answer 23

non contaminated, non traumatic, non inflamed surgical sites
GI, urinary, repsiratory tract not entered
surgical wound
aseptic technique maintained
tissues not predisposed to infection

Question 24

wound classification – clean-contaminated

Answer 24

GI, urinary, respiratory tracts entered under controlled conditions without unusual contamination
aseptic technique, no spillage of organ contents
some acute traumatic wounds that have been cleaned
minor break in sterility
placement of a drain in a “clean” wound

Question 25

wound classification -- contaminated

Answer 25

surgery where GI contents or infected urine spill into an open cavity major break in aseptic technique open fractures penetrating wounds new open traumatic wounds/lacerations antibiotics and lavage +/- debridement

Question 26

wound classification -- dirty and infected

Answer 26

heavily contaminated/infected purulent discharge, foreign material abscesses traumatic wounds > 12 hours after injury surgery where hollow organ/viscera perforated or fecal contamination occurs gross spillage of contamianted body contents antibiotics, lavage, debridement, drainage, +/- bandage

Question 27

initial approach of wound cleaning

Answer 27

protect with occlusive bandage provide analgesia drug therapy -- antibiotics wear gloves fill wound with water soluble lube -- prevent hairs from getting it while clipping clip and clean with wide margins do not use scrub in wound bed

Question 28

lavage

Answer 28

keep tissue hydrated reduce bacterial contamination remove necrotic debris dilution is the solution to pollution culture after lavage do not lavage puncture wounds

Question 29

why culture after lavage?

Answer 29

if do it before will just get significant contamination, will not get an accurate reading

Question 30

surgical debridement

Answer 30

freshening edges -- scalpel blade, may be some active bleeding sometimes only indicated in preparation for wound closure

Question 31

chemical (enzymatic) debridement

Answer 31

very expensive, not painful (no analgesia) poor anesthetic patients, minimal debridement very slow, not good for large wounds

Question 32

mechanical (bandaging) debridement

Answer 32

traps devitalized tissue in primary layer of bandage wet to dry vs dry to dry materials inexpensive painful -- materials stick to bandage have to change at least once per day

Question 33

biosurgical debridement

Answer 33

maggot therapy -- maggots eat dead tissue

Question 34

what to debride

Answer 34

contaminated SQ fat shredded fascia macerated muscle devitalized skin skin edges (3-5 mm)

Question 35

what not to debride

Answer 35

direct cutaneous vessels hypodermis cutaneous muscles bones with attachments ligament attached to bone nerves other vital structures

Question 36

what determines wound management plan

Answer 36

wound classification time since injury location of wound degree of contamination degree of tissue trauma extent of tension or dead space blood supply of wound clinical condition of patient results after debridement and lavage

Question 37

wound closure -- first intention

Answer 37

-primary closure -within a few hours after injury (6-8 hours) -best choice for healthy wounds in well vascularized areas -closed within 24 hours of injury with sutures or staples -minimal edema -no local infection or serous discharge -minimal scar formation -healing rapid -clean surgical or fresh traumatic wound after cleaning (clean-contaminated)

Question 38

should you close a contaminated wound

Answer 38

aggressively debride good blood supply no evidence of established infection less than 6 hours old

Question 39

wound closure -- third intention

Answer 39

-delayed primary closure (18-24 hours) -start wound management at 6-8 hours post injury -prior to granulation formation -wounds sutured closed before granulation tissue forms -moderate to marked tissue edema -older wounds -questionable viability -debride -significant swelling and/or skin tension -best for infected or unhealthy wounds that are too contaminated for primary closure -appear clean and well vascularized in 3-5 days -don't use for dirty or significantly contaminated wounds -contaminated or infected wounds, extremity wounds, wounds from blunt trauma

Question 40

wound closure -- secondary closure

Answer 40

-after granulation tissue present -wound closure > 5 days after injury -medical management of wound initially, then surgical closure -ensure wound in clear of infection before closing -excision of epithelialized edges and some granulation tissue may be required -recommended for infected wounds or large wounds -if primary closure fails can then use secondary closure

Question 41

wound closure -- second intention

Answer 41

-non closure -contraction and epithelialization -secondary wound healing or spontaneous healing -wound is left open -some may be surgically closed later (secondary closure) -recommended when patient is poor anesthetic candidate, infected wounds, large wounds -risk of contracture formation -- proud flesh in horses -moderate to small trunk wounds or burns -abscesses -- can't clear with initial lavage (don't want to suture bacteria into body) -distal extremity wounds -- not enough skin -fistulae -takes a long time, expensive

Question 42

wound closure -- epithelialization

Answer 42

healing of partial thickness wounds (includes first degree burns and abrasions)

Question 43

golden period

Answer 43

wound treated within 6-8 hours after injury bacterial levels not multiplied to critical numbers yet tissues not infected

Question 44

should wounds treated after the golden period be closed

Answer 44

no infection is likely

Question 45

tissue viability

Answer 45

don't want to suture dead/necrotic tissue into patient attachment color texture temperature

Question 46

bandaging

Answer 46

covers drains and wounds reduces dead space and edema debrides wounds (mechanically) vehicle for antiseptic immobilization cleanliness holds dressing in place

Question 47

primary layer of bandage -- dressing

Answer 47

directly on wound gauze or mesh material that promotes early healing allows fluid to pass through secondary layer and prevents tissue from drying out

Question 48

secondary layer of bandage

Answer 48

absorbs fluid pads the wound decreases dead space supports or immobilizes limbs frequently cast padding or roll gauze

Question 49

tertiary (outer) layer of bandage

Answer 49

provides some pressure on wound holds inner layers in place protects inner layers from environment usually adhesive tape or elastic wraps (vet wrap)

Question 50

hydrophilic foam

Answer 50

hydrophilic dressing maintains moist wound environment not too moist -- bacteria not too dry -- kills tissues low adherence to wound surface high fluid handling capacity decreased bandage changes decreased tissue maceration

Question 51

topical agents -- granulated sugar

Answer 51

inflammatory to early repair phase hyperosmotic requires frequent bandage changes exudative wounds decreased bacterial proliferation promotes debridement and granulation/epithelialization 1 cm thick layer SID to TID bandage changes

Question 52

topical agents -- honey

Answer 52

inflammatory to early repair phase hyperosmotic effect may damage healthy tissues requires frequent bandage changes manuka honey -- properties that promote wound healing promotes debridement, granulation, epithelialization reduces edema and inflammation easy to acquire and store, inexpensive messy

Question 53

topical agents -- silver

Answer 53

inflammatory and repair phases no clinical evidence of resistance

Question 54

topical agents -- antibiotics

Answer 54

inflammatory and repair phases broad spectrum may also supply zinc to the wound environment

Question 55

topical agents -- enzymatic agents

Answer 55

inflammatory phase slow, expensive

Question 56

topical agents -- biologic (maggots)

Answer 56

inflammatory phase selective debridement requires specialized dressing to contain the maggots

Question 57

when to place a drain

Answer 57

in place 3-7 days when dead space cannot be eliminated when fluid accumulation likely when infection present

Question 58

passive drains

Answer 58

relies on gravity, pressure differentials, overflow to move fluid/gas fluid exits around tube at incision site

Question 59

active drains

Answer 59

apply artificial pressure gradient to pull fluid/gas from wound involves suction

Question 60

management of cuts, tears, lacerations

Answer 60

usually complete closure damage to muscles, tendons, or other tissues must be treated before wound closure

Question 61

management of degloving injuries

Answer 61

usually requires bandaging

Question 62

management of puncture wounds

Answer 62

leave open explore? possibility of underlying trauma

Question 63

managemnet of abscesses

Answer 63

establish draining lavage copiously warm compresses antibiotics?

Question 64

management of open fractures

Answer 64

rapid wound care and culture bandage/splint antibiotics analgesics surgery consultation ASAP

Question 65

complications -- seroma

Answer 65

layered wound closure drains

Question 66

complications -- infection

Answer 66

debridement antimicrobials +/- supportive care

Question 67

complications -- dehiscence

Answer 67

tissue viability closure technique

Question 68

complications -- failure to heal

Answer 68

patient status closure method